CaucasianBlack Hispanic or LatinoWhite Hispanic or LatinoAmerican Indian or Alaskan NativeAsianAfrican AmericanNative Hawaiian and other Pacific IslanderRefused

Language preference

Email address

May we send test results to you by email?

YesNo

May we send your billing statement by email?

YesNo

Parent/Guardian (if patient is under 18)

Billing address

First name

Middle initial

Last name

Date of birth (MM/DD/YYYY)

Home phone

Cell phone

Work phone

Insurance Information

Insurance subscriber (main policy holder) name

Date of birth

(Fill out if we did NOT take a copy of your Insurance Card)

Insurance company

Company phone

Medical billing address

Member/subscriber number

Group/policy number

**Assignment of Insurance Benefits** I hereby authorize Longs Peak Family Practice to recover from my insurance company, payment for any health service that is provided to me. I understand that I am financially RESPONSIBLE for ALL co-pays, co-insurance, deductibles, and non covered charges that is determined by my insurance company. I hereby authorize Longs Peak Family Practice to release all information necessary to secure such payments. A photocopy or electronic scan of this statement is to be considered as valid as the original.